SITUATIONS RESPONSES TO SUICIDE CRISIS - PARTNERS IN PREVENTION: Queensland Centre For Mental Health Research

 
SITUATIONS RESPONSES TO SUICIDE CRISIS - PARTNERS IN PREVENTION: Queensland Centre For Mental Health Research
PARTNERS IN PREVENTION:

UNDERSTANDING AND
ENHANCING FIRST
RESPONSES TO
SUICIDE CRISIS
SITUATIONS
OPTIMAL CARE
PATHWAYS
SITUATIONS RESPONSES TO SUICIDE CRISIS - PARTNERS IN PREVENTION: Queensland Centre For Mental Health Research
ACKNOWLEDGEMENTS
    We would like to acknowledge the Traditional Custodians of the land on which our
    services are located. We pay our respects to the Elders both past and present and
    acknowledge Aboriginal and Torres Strait Islander peoples across the State. We
    continue to recognise that to Close the Gap we need to work together with Aboriginal
    and Torres Strait Islander people, communities, staff and stakeholders to ensure that
    we are meeting the needs of the community.

    We acknowledge those who experience suicidality and those lost to suicide, and their
    families, friends, loved ones, and others who are affected by suicide.

                                                                                  The authors acknowledge the consultation
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Queensland Police Service                                                         © State of Queensland (Queensland Health)
                                                                                  2020
The authors wish to acknowledge the support
and assistance from the Queensland Police                                         You are free to copy, communicate and adapt
Service in undertaking this research. The views                                   the work, as long as you attribute the State of
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any errors of omission or commission are the                                      ISBN: 978-0-6487789-4-3
responsibility of the authors.
                                                                                  Suggested citation
Roses in the Ocean                                                                Queensland Forensic Mental Health Service,
The views expressed by people with a lived                                        Metro North Hospital and Health Service, and
experience of suicide engaged in consultation                                     Queensland Centre for Mental Health Research.
throughout this project and publication are their                                 2020. Partners in Prevention: Understanding
own specific perspectives and do not endeavour                                    and Enhancing First Responses to Suicide Crisis
to represent all lived experience perspectives.                                   Situations – Optimal Care Pathways for People
We acknowledge that all lived experience                                          in Suicidal Crisis who Interact with Police or
insights are valuable and important.                                              Paramedics. Brisbane: Queensland Health.
Queensland Alliance for Mental Health                                             This literature review was prepared by:
(QAMH)                                                                            Dr Katelyn Kerr1,2,3, Clinical Psychologist in
Queensland Alliance for Mental Health (QAMH) is                                   consultation with: Dr Carla Meurk4,5, Dr Elissa
the peak body for the community mental health                                     Waterson4,5, Associate Professor Ed Heffernan4,5
sector in Queensland.

1
 Life Promotion Clinic, Australian Institute for Suicide Research and Prevention
2
  Day Programs, Toowong Private Hospital
3
  Savoir Rooms Specialist Medical Practice
4
  Queensland Centre for Mental Health Research
5
 Queensland Forensic Mental Health Service, Metro North Hospital and Health Service

PARTNERS IN PREVENTION: UNDERSTANDING AND ENHANCING FIRST RESPONSES TO SUICIDE CRISIS SITUATIONS
SITUATIONS RESPONSES TO SUICIDE CRISIS - PARTNERS IN PREVENTION: Queensland Centre For Mental Health Research
OPTIMAL CARE PATHWAYS

OVERVIEW
Individuals who experience a suicide crisis often come into contact with police or paramedics. Those who have experienced a
suicide crisis report deficiencies with the existing system, and police and paramedics report that responding to these events
is one of the most challenging aspects of their role. However, little is known about the nature, extent, precipitating factors,
pathways and outcomes of a suicide related call-out, and what responses will most effectively and compassionately meet the
needs of those in crisis. Partners in Prevention: Understanding and Enhancing First Responses to Suicide Crisis Situations,
funded by the Queensland Health Suicide Prevention Health Taskforce, was established in 2017 to address these knowledge
gaps and inform systems enhancements.

Project overview
The Partners in Prevention project encompassed five major initiatives:

                  DATA LINKAGE
                  A linked data study about individuals who came into contact with Queensland Police Service or
                  Queensland Ambulance Service between 2014 and 2017, and their health services use and outcomes
                  between 2013 and 2018.

                  SERVICE MAPPING
                  An integrated service mapping of collaborative services involving police, ambulance and mental health
                  services up to January, 2018.

                  PERSPECTIVES FROM LIVED EXPERIENCE
                  A workshop to gather lived experience perspectives on optimal first responses to suicide crisis situations,
                  and situations involving a recent bereavement due to suicide.

                  LITERATURE REVIEWS
                  Reviews of literature on: optimal care pathways following a suicide-related call to emergency services;
                  evaluation frameworks for collaborative suicide crisis interventions; and data linkage studies in
                  suicidology.

                  KNOWLEDGE, SKILLS, ATTITUDES AND CONFIDENCE OF POLICE
                  A mixed methods study of knowledge, skills, attitudes and confidence of police in responding to suicide
                  crisis situations.

Our partners

                    QUEENSLAND CENTRE FOR
                                                                                  ROSES IN THE OCEAN
                    MENTAL HEALTH RESEARCH

                    QUEENSLAND AMBULANCE SERVICE                                  BRISBANE NORTH PHN

                    QUEENSLAND HEALTH                                             QUEENSLAND ALLIANCE FOR MENTAL HEALTH

                    QUEENSLAND POLICE SERVICE                                     QUEENSLAND MENTAL HEALTH COMMISSION

                                                                                                                    1
SITUATIONS RESPONSES TO SUICIDE CRISIS - PARTNERS IN PREVENTION: Queensland Centre For Mental Health Research
CONTENTS
OVERVIEW                                                                                                                   1

SUMMARY                                                                                                                    3

INTRODUCTION                                                                                                               4

METHODS                                                                                                                    4

RESULTS                                                                                                                    5

  Co-responder models                                                                                                     12

  Brief contact interventions                                                                                             15

  Short stay safe havens                                                                                                  16

  Blended models                                                                                                          19

  Culturally appropriate crisis responses                                                                                 20

  Aftercare services                                                                                                      22

DISCUSSION                                                                                                                26

CONCLUSION                                                                                                                26

REFERENCES                                                                                                                27

          2            PARTNERS IN PREVENTION: UNDERSTANDING AND ENHANCING FIRST RESPONSES TO SUICIDE CRISIS SITUATIONS
SITUATIONS RESPONSES TO SUICIDE CRISIS - PARTNERS IN PREVENTION: Queensland Centre For Mental Health Research
OPTIMAL CARE PATHWAYS

SUMMARY
Why we did this
Tailored, effective interventions, that can be delivered during or immediately following the first response to someone in a
suicidal crisis, are vital in order to support a person out of a crisis and prevent future suicide attempts. The predominant health
pathway used by first responders in Australia is transportation to a hospital emergency department. Recent reports have
highlighted significant barriers to care that await those presenting to emergency departments with mental health problems,
including suicidal crises. Individuals with lived experience of suicide are increasingly vocalising the view that emergency
departments are often inappropriate therapeutic environments.

What we did
We undertook a literature review with the following two aims:
1. To examine the existing evidence-base on optimal models of care relevant following a suicidal crisis, for those who interact
   with police or paramedics, including models that are relevant for specific populations (e.g., those identifying as Aboriginal
   or Torres Strait Islander, veterans); and

2. To synthesize literature and highlight approaches to high quality care that could be established in Queensland.

A comprehensive search of peer reviewed literature, as well as grey literature and articles provided by experts, was undertaken.

What we found
The following six types of models of care were identified:
1. Co-responder models
2. Brief contact interventions
3. Short stay safe havens
4. Blended models
5. Culturally appropriate crisis responses
6. Aftercare services

The review found a number of different models that have been trialled nationally and internationally. However, varied intake
criteria, staffing composition, and evaluation methods make it difficult to compare and contrast services. Many articles did not
elaborate on how services were delivered in a way that would allow replication. Evaluations often did not provide or investigate
outcomes for consumers both short and longer term nor have a comprehensive system of evaluation in place.

Conclusions
Several models of care that may meet the needs of individuals who experience suicidal crisis were identified. While these
services show great promise, there are gaps in the evidence-base relating to these services. Implementation of these services
should be supported by the establishment of comprehensive evaluation frameworks. Further gaps that were identified include
limited tailoring to vulnerable sub-groups and those under the age of 18.

                                                                                                                      3
SITUATIONS RESPONSES TO SUICIDE CRISIS - PARTNERS IN PREVENTION: Queensland Centre For Mental Health Research
INTRODUCTION
Recent figures highlight the tragedy of suicide in Australia,        more for admission following assessment and treatment)
with suicide deaths in 2017 sitting at a ten-year maximum            (Australasian College for Emergency Medicine, 2018).
of 12.6 deaths per 100,000 persons (Australian Bureau of
Statistics, 2018). Suicide is often preceded by a suicidal crisis    The World Health Organization advises that first responders
or crises.                                                           attending to someone in suicidal crisis should ensure that
                                                                     significant others are present and accept responsibility for
Approximately three out of every 100 Australian adults will          helping a person in suicidal crisis to gain help, rather than
attempt suicide during their lifetime and more than four out         leaving the person alone (World Health Organization, 2009).
of every 1000 Australian adults will make an attempt in any          Yet, there is no guidance for first responders on minimal or
one year (Johnston, Pirkis, & Burgess, 2009).                        non-interventionist approaches that would empower and
                                                                     allow individuals in crisis to remain safely in situ. While the
First responders play a crucial role in helping people through       harms of over medicalising, institutionalising or depriving the
suicidal crises and facilitating appropriate intervention and        liberty (through exercise of legislative powers) of those who
follow up. The World Health Organization acknowledges                experience mental health problems or suicidal crisis are well
that: “first responders are in a unique position to determine        known, the use of legislative powers to involuntarily transport
the course and outcome of suicidal crises” (World Health             individuals in crisis to an emergency department are often
Organization, 2009). Tailored, effective interventions that          viewed as the only available solution. At present, there are no
can be delivered during or immediately following the first           national guidelines on optimal care pathways to facilitate the
response are vital in order to support a person out of a crisis      diversion of people in a suicidal crisis from presenting to an
and prevent future suicide attempts. The first response to           emergency department (Wilhelm et al., 2007).
a suicidal crisis represents an opportunity to save a life,
but also for first responders to de-stigmatise talking about
suicide, build rapport with the person in crisis, gain trust, and    Aims
foster positive public perceptions of their professions.
                                                                     This current review had two aims:
In the Pathways to Care report (McPhedran & De Leo, 2013),
it was identified that the predominant pathway used by               1. To examine the existing evidence-base on models of
                                                                        care following a suicidal crisis, for those who interact
first responders for persons who are in, or at high risk of,
                                                                        with police or paramedics, including models that are
a suicidal crisis is transportation to a hospital emergency
                                                                        relevant for specific populations (e.g., those identifying
department (McPhedran & De Leo, 2013). The World Health                 as Aboriginal or Torres Strait Islander; young Australians;
Organization recommends this approach when a person is                  veterans; and older Australians); and
considered a high or imminent risk to themselves or others
(World Health Organization, 2009). However, when safety              2. To synthesize literature and highlight approaches to high
can be met in other ways, it is recommended first responders            quality care that could be established in Queensland.
ensure fast access to mental health treatment (World Health
Organization, 2009). There is limited, if any, peer-reviewed
evidence that transportation to hospital is an optimal
response.                                                            METHODS
Recent reports published by the Australian Government                For the purposes of this review, we defined a suicidal crisis
Productivity Commission (2019) and Australasian College              as encompassing: suicidal ideation, threatened suicide,
for Emergency Medicine (2018) have highlighted significant           threatened intentional self-harm, intentional self-harm,
barriers to care that await those presenting to Australian           suicidal behaviours, and suicide attempts. First responders,
emergency departments with mental health problems,                   here, refer to police or paramedics.
including suicidal crises. At the same time, individuals with
lived experience of suicide are increasingly vocalising the view
that emergency departments are inappropriate therapeutic
environments for many of those who are experiencing
crisis (Meurk & Smith, 2020). People with mental health
problems are less likely than those presenting with other
types of problems to be seen in the emergency department
within clinically recommended waiting times (Productivity
Commission, 2019), and are disproportionately likely to
experience access block (defined as waiting eight hours or

         4              PARTNERS IN PREVENTION: UNDERSTANDING AND ENHANCING FIRST RESPONSES TO SUICIDE CRISIS SITUATIONS
SITUATIONS RESPONSES TO SUICIDE CRISIS - PARTNERS IN PREVENTION: Queensland Centre For Mental Health Research
OPTIMAL CARE PATHWAYS

Search strategy                                                   Screening and data extraction
The search comprised a database search of peer reviewed           Documents were screened for inclusion/exclusion through
literature and grey literature, supplemented by consultation      title and abstract screening (title and executive summary
with known experts and snowballing from the original corpus       screening for reports). For all documents included, the
of information.                                                   following information was extracted: Reference details;
                                                                  model description (including name, type and staffing);
Academic databases searched were: PubMed, PsycInfo, and
                                                                  setting (location); consumer characteristics (age, gender,
The Griffith University Library Repository. A grey literature
                                                                  and characteristics of presentation); evaluation type (if
search was guided by clinical knowledge, and consultation
                                                                  conducted); period of evaluation; sample characteristics
with known experts to identify candidate care types that
                                                                  (number of cases/individuals); outcome measures collected;
could comprise a relevant model of care. For each of the
                                                                  and key outcomes reported.
models identified, the lead author (Dr Katelyn Kerr) sought to
identify peer reviewed or published evaluations, and made
direct contact with service providers to uncover published or
unpublished materials.                                            Analysis
                                                                  Literature was categorised into care types. An initial
                                                                  grouping was undertaken by Dr Katelyn Kerr and Dr Carla
Inclusion criteria                                                Meurk, before being verified by all authors and then
                                                                  discussed among the Partners in Prevention Steering Group.
Following initial scoping of the literature available, we took
                                                                  Available information for each model was summarised
an iterative approach to identifying and including literature,
                                                                  individually.
based on an evolving conceptual framework of potential
care pathways for individuals in suicidal crisis who come in
contact with first responders. An initial conceptual framework
was developed that focussed on identifying literature with
respect to the seven domains of: 1. ‘doing nothing’; 2. co-
                                                                  RESULTS
responder models; 3. alternatives to emergency department         Fourteen peer reviewed and grey literature articles, spanning
presentations; 4. involuntary or voluntary transportation         the following six categories of care type, met the criteria for
to emergency departments; 5. safe-haven café’s; 6.                inclusion:
transportation to the watch-house; and 7. field based brief
interventions. This framework was refined iteratively, through    1. Co-responder model
consultation between Dr Katelyn Kerr and Dr Carla Meurk,          2. Brief contact interventions
based on available literature. Care types were included in this   3. Short stay safe havens
review if they met the following criteria:
                                                                  4. Blended models
1. they had been developed explicitly for populations in
                                                                  5. Culturally appropriate crisis responses
   suicidal or mental health crises who come in contact with
   first responders; OR                                           6. Aftercare services
2. they were judged by the authors to share important             Table 1 provides a summary of models of care and literature
   similar features with models that met criteria 1; OR           included in this review, in terms of models of care type, study
3. they were judged by the authors to be a potential pathway      characteristics, and population of interest. Table 2 provides a
   for those who come in contact with first responders.           summary of models of care and literature in relation to clinical
                                                                  outcomes measured, case characteristics and outcomes.
Due to the limited evidence-base, inclusion was based on
relevance. No exclusion criteria were set in relation to study
type or availability of a formal published evaluation. No
quality appraisal of evidence was undertaken as a basis for
inclusion or exclusion of models or literature presented.

                                                                                                                     5
Table 1 Summary of literature, describing models of care, study characteristics and population of interest.

 Model name; description                                 Author & Year       Staffing                  Evaluation Type/       Sample characteristics/                   Setting         Study period   Gender    Age
                                                                                                       Design                 inclusion criteria

 1.   Co-responder – mental health clinician co-responds with police or paramedics. May provide advice, conduct mobile assessments, and/or take over the care of a person in suicidal crisis

 Review of co-responder models; various                  Puntis et al.       Various                   Systematic review      Various                                   Various         Various        Various   Various
                                                         (2018)                                        of descriptive and
                                                                                                       qualitative studies.

 Psychiatric Emergency Response Team (PAM);              Bouveng,            Paramedics and mental     Descriptive study      N=1,580 requests for service, data        Stockholm,      2015-2016,     56%       No age restrictions.
 mental health professionals attend emergency            Bengtsson, &        health professionals                             reported on N=1,036 individuals with      Sweden          12 months      Female.   Age range of cohort seen 5-100
 calls with paramedics, involving members of the         Carlborg (2017)                                                      severe mental illness or in suicidal                                               years.
 community with severe mental illness or acute                                                                                crisis.
 suicide risk.

 Police Ambulance Clinical Early Response (PACER);       The Allen           Police and mental         Pre-post study with    N=783 assistance requests for             Victoria,       2009-2011,     Not       No age restrictions reported.
 secondary units engaged by police or paramedic          Consulting          health professionals      control group.         service for                               Australia       16 months      given.
 first responders via police communications centre,      Group (2012)                                                         individuals in a suicidal or mental
 local Crisis Assessment and Treatment Teams, or                                                                              health crisis.
 the police Officer in Charge.

 A-PACER; as above                                       Lee et al. (2015)   Police and mental         Descriptive study      N=296 contacts for service for            Victoria,       2011-2012, 6   60%       No age restrictions reported.
                                                                             health professionals      (mixed methods).       individuals in a suicidal or mental       Australia       months         Male.
                                                                                                                              health crisis.

 West Moreton co-responder; mental health                Meehan, Brack,      Police and mental         Pre-post study         N=171 individuals; N=226 occasions        West Moreton,   2017, 4        49%       No age restrictions. 51% aged
 clinicians work alongside police. Mental health         Mansfield, &        health professionals      (interrupted time      of service. Direct contact with           Queensland,     months         Female.   20-39 years.
 co-responder undertakes rapid triage following          Stedman (2019)                                series)                N=137. Information on disposition         Australia.
 on-site assessment by police, advises on referrals                                                                           following contact available for N=122.
 to ED or other services, and undertakes follow-up.                                                                           Individuals were those in a suicidal or
                                                                                                                              mental health crisis.

 2.   Brief Contact Interventions – time limited, structured interventions focussed on problem solving, crisis planning, and linking to other services.

 Distress Brief Intervention (DBI); A time limited (14   O’Neill (2018)      Stage one delivered       Currently underway.    Interim findings reported on 1,322        Four trial      2016-2021,     Not       Originally developed for adults,
 days) problem-solving intervention available in                             by police, paramedics,                           referrals received up to September,       sites across    ~4.5 years     given.    but undergoing expansion in
 addition to services as usual.                                              ED or primary care                               2018. Individuals in distress who         Scotland                                 stages to include 16 and 17 year
                                                                             professionals; stage                             come to the attention of police,                                                   olds, and scope feasibility for
                                                                             2 delivered by mental                            ambulance, hospital EDs, or primary                                                those aged 15 years and younger.
                                                                             health professionals                             care.
                                                                             and peer support
                                                                             workers with lived
                                                                             experience.

 3.   Short stay safe havens – safe, comfortable spaces for people in suicide or mental health crisis to go, as an alternative to presenting to an ED.

 Aldershot Safe Haven Service; A walk-in centre          Griffiths & Gale    Mental health             Mixed design.          N=4,275 attendances at the service,       Aldershot,      2016-2017,     Not       Indicates the service is for adults
 that provides an alternative to ED presentation for     (2017)              professionals and peer    Interrupted time       approximately 670 individuals             Hampshire,      12 months      given.    (18 years and over).
 adults in crisis.                                                           support workers with      series of impacts,     needing mental health support out         United
                                                                             lived experience.         descriptive study of   of hours.                                 Kingdom
                                                                                                       client satisfaction.

            6                  PARTNERS IN PREVENTION: UNDERSTANDING AND ENHANCING FIRST RESPONSES TO SUICIDE CRISIS SITUATIONS
Model name; description                                Author & Year       Staffing                    Evaluation Type/     Sample characteristics/                   Setting         Study period    Gender   Age
                                                                                                       Design               inclusion criteria

St Vincent’s Safe Haven Café; provides a safe,         Price               Mental health               Cost-benefit         N=41 participants who completed           Melbourne,      2018, 5         Not      Indicates the service is for
supportive and welcoming place for people to           Waterhouse          professionals; peer         analysis             a survey. Data on ED presentations        Victoria        months          given.   adults.
gain information on support options available to       Coopers (2018)      support workers with                             from May-September 2018 were                              (compared
them, understand more about reactions to crises,                           lived experience;                                compared with data from the same                          with: 5
and facilitate development of therapeutic skills to                        volunteers.                                      period one-year prior and six months                      months
manage crises and improve mental health. Free                                                                               immediately prior. (N=62 participants                     period 12
tea, coffee and snacks are provided.                                                                                        individuals made 400 visits to the                        months
                                                                                                                            café over this period.) Individuals                       prior; and
                                                                                                                            were people seeking mental health                         previous 6
                                                                                                                            support, including loneliness,                            months)
                                                                                                                            personal difficulties, or seeking
                                                                                                                            social connection.

Brisbane North Safe Space; Safe Space provides         –                   Non-clinical staff          None currently.      –                                         –               –               –        –
a warm, welcoming, supportive environment that
people can go to when experiencing psychological
distress. Activities are offered.

The Living Room (TLR); A community-based               Heyland, Emery,     Mental health               Descriptive study    N=56 visits, N=16 clients participated    Chicago,        2015, 8         Not      No age restrictions reported.
alternative to ED available to “guests” in an          & Shattell (2013)   professional and peer                            in study;                                 Illinois,       weeks           given.   However, findings limited to
emotional crisis. The approach is recovery             Heyland &           support workers with                             N=228 visits, 87 individuals in mental    United States   (clients                 those 18 years of age or over.
orientated and the TLR environment is arranged         Johnson (2017)      lived experience.                                health crisis.                            of America      followed up
like a home living room to maximise guests’                                                                                                                                           30 days post
comfort.                                                                                                                                                                              separation
                                                                                                                                                                                      with service)

4.   Blended models - a holistic, multi-factorial model of service, beginning at the point of call and that combines multiple service elements.

Crisis Now; A comprehensive model of care. Model       –                   Mental health               None currently       –                                         –               –               –        –
is centred around principles and practices of                              professionals; peer
recovery focussed, trauma-informed treatments,                             support workers with
use of peer workers, commitment to safety                                  lived experience; non-
and zero suicide, and collaboration with law                               clinical staff.
enforcement.

5.   Culturally appropriate crisis responses - crisis services that focus on the needs of specific cultural groups.

Aboriginal and Torres Strait Islander Suicide          Dudgeon,            Non-clinical staff.         Study design/        N=46 Aboriginal and/or Torres             Four trial      2015-2016,      Not      No age restrictions reported.
Prevention Evaluation Project (ATSIPEP);               Milroy, Luxford,                                methodology not      Strait Islander families affected by      sites across    ~ 12 months     given.
Comprises two components: A Critical Response          & Holland (2017)                                described            suicide or critical incident, including   Western
Stream (CRS) operating state-wide with the                                                                                  suicide or situation where suicide        Australia
role of providing assistance to Indigenous                                                                                  is a high risk, murders, or multiple
families following a suicide; and a Community                                                                               casualty events, that place family, kin
Development Stream (CDS) operating in four                                                                                  and community of the deceased at
sites to upskill communities in suicide prevention                                                                          elevated suicide risk.
activities and critical responses.

National Indigenous Crisis Response Service            –                   Non-clinical staff          None currently       –                                         –               –               –        –
(NICRS); Similar to ATSIPEP (above)                                        identifying as              (however, informed
                                                                           Aboriginal and/or           by ATSIPEP
                                                                           Torres Strait Islander.     evaluation)

                                                                                                      PARTNERS IN PREVENTION: UNDERSTANDING AND ENHANCING FIRST RESPONSES TO SUICIDE CRISIS SITUATIONS
                                                                                                                                                                                                                                  7
Model name; description                                Author & Year       Staffing                    Evaluation Type/      Sample characteristics/                   Setting     Study period   Gender    Age
                                                                                                       Design                inclusion criteria

6.   Aftercare services - Services that link people in need to appropriate services to prevent suicidality in the future.

The Way Back; A non-clinical, short term support       beyondblue          Non-clinical staff          Mixed design.         N=122 referrals, N=87 individuals         Darwin,     2014-2015,     40%       No age restrictions reported.
service that provides linkages to support networks     (2016)              with human services         Pre-post study        who were recently discharged from         Northern    18 months      Male.     78% under 45 years of age.
in the first three months after discharge. Clients                         training.                   (quantitative         hospital for a suicide attempt or         Territory
can access the program via referral from ED or a                                                       and qualitative).     suicidal crisis. N=46 interviews with
psychiatric inpatient ward.                                                                            Descriptive           stakeholders.
                                                                                                       study of client
                                                                                                       characteristics.

PAUSE; A peer support program recently                 –                   Peer support workers        Currently underway.   –                                         –           –              –         –
implemented by Brook RED in Brisbane. The                                  with lived experience.
intervention delivered is individualised and
tailored to the person based on their needs,
including peer support focussed on recovery,
advocacy, linkage to services, and providing
education to carers and family members of the
person.

Green Card Clinic; provide expedited access to         Wilhelm et al.      Mental health               Mixed design.         N=456 individuals who presented to        Sydney,     1998-2005,     57%       No age restrictions reported.
three structured treatment sessions with trained       (2007)              professionals.              Pre-post study        St Vincent’s hospital ED for deliberate   Australia   7 years        Female.   Mean age =31.6 years.
clinicians, following deliberate self-harm or                                                          of outcomes,          self-harm or suicidal ideation.
suicidal crisis.                                                                                       descriptive
                                                                                                       study of client
                                                                                                       characteristics and
                                                                                                       feedback.

Pieta House; a suicide intervention outpatient         Surgenor,           Mental health               Pre-post study.       N=432 individuals in suicide crisis       Ireland     No date        44%       No age restrictions reported. Age
service for people who are actively suicidal, who      Freeman, &          professionals.                                    who were invited to participate pre-                  range given    Male.     range 18-74.
self-harm, or who have made a suicide attempt;         O’Connor (2015)                                                       therapy.
intensive therapy is delivered over a timeframe of
up to 12 weeks.

Veteran Suicide Prevention Pilot                       –                   Non-clinical staff          None currently.       –                                         –           –              –         –

ED: Emergency Department

          8                   PARTNERS IN PREVENTION: UNDERSTANDING AND ENHANCING FIRST RESPONSES TO SUICIDE CRISIS SITUATIONS
Table 2 Summary of models of care and literature in relation to clinical outcomes measured, case characteristics and outcomes.

 Model Name;                 Clinical outcomes measured           Key Findings - Case characteristics         Key Findings - Outcomes
 Author & Year

 1.   Co-responder – mental health clinician co-responds with police or paramedics. May provide advice, conduct mobile assessments, and/or take over the care of a person in suicidal crisis

 Review of co-responder      No                                   NA                                          • Lack of consistency in evaluation methods, no         • Some evidence for reduction in use of police powers with the ride-along model.
 models (Puntis et al.,                                                                                         randomised controlled trials.                         • Lack of evidence regarding cost effectiveness or clinical outcomes.
 2018)                                                                                                        • Unclear  whether co-responder model had an
                                                                                                                impact on psychiatric hospitalisations.

 Psychiatric Emergency       No                                   97% of requests received had high            • Of those assessed by PAM, 17% were assessed as high or very high suicide risk.
 Response Team (PAM)                                              or medium priority. Reasons for              • PAM was well received by stakeholders.
 (Bouveng et al., 2017)                                           attendance were: Severe suicide
                                                                                                               For the people PAM was in contact with, outcomes were:
                                                                  threat (36%);
                                                                  suspicion of severe psychiatric illness      • No action or referral to other services (34%);         • Job handed over to paramedics (10%);
                                                                  (25%).                                       • Admitted to psychiatry ED (25%);                       • Admitted to psychiatric child care (4%);
                                                                                                               • Admitted to substance use ED (18%);                    • Person died by suicide at arrival (0.3%);
                                                                                                                                                                        • Other or unknown (10%).
 Police Ambulance            No                                   Reason for attendance were:                 Of those assessed by PACER:
 Clinical Early Response
 (PACER) (The Allen
                                                                  Concern for individual’s welfare
                                                                  (48%); section 10 apprehensions
                                                                                                              • 64%  of those assessed by PACER did not
                                                                                                                require transportation.
                                                                                                                                                                      • Proportionally more cases were transported by ambulance than police in the
                                                                                                                                                                        PACER site, compared with the comparator site (40% police and 45% ambulance
 Consulting Group,                                                (37%).
                                                                                                              • 43%  of those that did not require                       versus 61% police and 37% ambulance).
 2012)                                                                                                          transportation had been attended to for
                                                                                                                 threats of suicide, self-harm or harm to others.
                                                                                                                                                                      • Proportionally fewer cases were transported to ED at the PACER site in
                                                                                                                                                                        comparison to the comparator site. (34% versus 84% for police; 79% versus 86%
                                                                                                              • Use of force by police decreased in the PACER            for ambulance).
                                                                                                                area and increased in the comparator site.            • Proportionally more cases were transported to a psychiatric facility at the PACER
                                                                                                              • 36%  of cases required transportation from
                                                                                                                the PACER site, compared to 99% in the
                                                                                                                                                                        site in comparison to the comparator site (30% versus 15% for police; 19% versus
                                                                                                                                                                         8% for ambulance).
                                                                                                                 comparator site.

 A-PACER (Lee et al.,        No                                   The two most common reasons for             Outcome of A-PACER referral:
 2015)                                                            referral were: Threatened suicide
                                                                                                              • 32% were transported to ED;                           • 20% did not require further assistance;
                                                                  (33%); Welfare concerns (22%).
                                                                                                              • 22% were referred to another service;                 • 11% were directly admitted to a psychiatric unit;
                                                                                                                                                                      • 9% of contacts resulted in a criminal charge.
 West Moreton Co-            No                                   The two most common reasons for             For the 122 people who had direct contact with the co-responder team:
 Responder (Meehan et                                             referral were: Threatening suicide/
                                                                                                              • 67% remained at the scene;                            • There was a statistically significant reduction in mental health related ED
 al., 2019)                                                       self-harm (60%); Situational crisis
                                                                                                              • 29% were transported to ED (51% were                    presentations for the six-month period after the program was introduced.
                                                                  (22%). 36% of individuals had had             admitted);                                            • 23%  were transported to hospital under an Emergency Examination Authority
                                                                  previous contact with a mental health
                                                                  service. 7% were currently case
                                                                                                              • 4% were taken into police custody.                      (Public Health Act).

                                                                  managed by a mental health service
                                                                  at the time of the crisis.

                                                                                                            PARTNERS IN PREVENTION: UNDERSTANDING AND ENHANCING FIRST RESPONSES TO SUICIDE CRISIS SITUATIONS
                                                                                                                                                                                                                                           9
Model Name;                Clinical outcomes measured          Key Findings - Case characteristics      Key Findings - Outcomes
Author & Year

2.   Brief Contact Interventions - time limited, structured interventions focussed on problem solving, crisis planning, and linking to other services.

Distress Brief             None reported so far.              Provisional outcomes (as of               • 78% of the appropriate concluded cases                • Data available up to 24 May, 2018 indicate overall reduction in distress among
Intervention (DBI)                                            September, 2018):                             engaged in further DBI support                         participants of 50% from intake to the end of DBI level 2.
(O’Neill, 2018)                                               •  24% self-reported being under the
                                                                 influence of alcohol/substances at
                                                                 point of referral.
                                                              Presenting problems reported,
                                                              included:
                                                              • Stress/anxiety;       • Suicidal
                                                                                       ideation;
                                                              • Low mood;    • Self-harm.

3.   Short stay safe havens - safe, comfortable spaces for people in suicide or mental health crisis to go, as an alternative to presenting to an ED

Aldershot Safe Haven       No                                 Reasons for attendance:                   Of those who had previously attended an ED:
Service (Griffiths &
                                                              • 56% crisis prevention;                  • 53% showed a decrease in ED attendance                • 28% showed an increase in their attendance at ED.
                                                              • 23% ‘social reason’;
Gale, 2017)
                                                                                                            following introduction to Safe Haven;
                                                              • 13% crisis;
                                                              • 7% other.                               Additional outcomes reported, were:

                                                                                                        • 16% reduction in admission to acute inpatient         • Reduced police deployments in the area of the Safe Haven (66% of calls resulted
                                                                                                            psychiatric beds in the Safe Haven service             in deployment versus 43% of calls resulted in police deployment. Qualitative data
                                                                                                            catchment area, 12 months post;                        indicate that this is linked to the ability to refer to Safe Haven cafés.). Service
                                                                                                        •   42% drop in calls marked “mental health                users rated Safe Haven favourably.
                                                                                                            related” from 2013 to 2016 with the
                                                                                                            introduction of Safe Haven;

St Vincent’s Safe Haven
Café (Price Waterhouse
                           No                                 NA                                        • 37% of the 41 people who completed a sign in          • Modelling based on ED data suggested that 12% of presentations to the café would
                                                                                                            sheet reported they would have gone to ED if           have resulted in an ED presentations, had the café not existed (60 presentations
Coopers, 2018)                                                                                              the Safe Haven was not open. This equates to           over six months).
                                                                                                            151 ED presentations that were diverted in a six-
                                                                                                            month period based on the self-report data.

Brisbane North Safe        –                                  –                                         –
Space

The Living Room (TLR)
(Heyland & Johnson,
                           Subjective Units of Distress
                           Rating (SUDS) (0 no distress –
                                                              SUDS score on arrival was 7.7.
                                                              Presenting problems: stress + anxiety
                                                                                                        • Guests reported an average SUDS reduction of          • 94% reported they did not re-attend at ED within the 30-day follow-up.
                                                                                                            approximately 2 points on departure.
2017; Heyland et al.,      10 highest distress). Measured     or depression (62.5%); anxiety (25%).
2013)                      on arrival and discharge (not                                                Guests at TLR reported the following as beneficial outcomes of engagement:
                           linked to evaluation).
                                                                                                        • Talking with someone about the problem and            • Resources and referrals provided by staff (40%);
                                                                                                          using problem solving skills (80%);                   • Other specific person-centred factors, such as goal setting, finding the staff helpful,
                                                                                                        • Learning coping skills (67%);                            liking the comfort of the environment (40%).
                                                                                                        • Reassurance of knowing the Living Room was
                                                                                                            there if needed (53%);

         10                    PARTNERS IN PREVENTION: UNDERSTANDING AND ENHANCING FIRST RESPONSES TO SUICIDE CRISIS SITUATIONS
Model Name;                 Clinical outcomes measured           Key Findings - Case characteristics        Key Findings - Outcomes
Author & Year

4.   Blended models - a holistic, multi-factorial model of service, beginning at the point of call and that combines multiple service elements.

Crisis Now                 –                                     –                                          –

5.   Culturally appropriate crisis responses - crisis services that focus on the needs of specific cultural groups.

Aboriginal and Torres       No                                   21 families directly helped.               21 families directly helped.
Strait Islander Suicide
Prevention Evaluation                                                                                       Services completed:                                   • 497 telephone calls with services, 72 tele-meetings with services;
Project (ATSIPEP)
(Dudgeon et al., 2017)
                                                                                                            • 354  telephone calls with affected families, 45
                                                                                                              tele-meetings with affected families;
                                                                                                                                                                  • Conducted 92 face-to-face meetings with families and community groups.
National Indigenous         –                                    –                                          –
Crisis Response Service

6.   Aftercare services - Services that link people in need to appropriate services to prevent suicidality in the future.

The Way Back
(beyondblue, 2016)
                            WHO-5 – World Health
                            Organisation, Well-Being Index
                                                                 14% of participants identified as
                                                                 Aboriginal and/or Torres Strait
                                                                                                            • Mean score on exit was 22.5.                        • Qualitative data indicate that clients were highly satisfied with the service.
                            (0=worst imaginable well-            Islander. N=13 clients completed a
                            being – 25=best imaginable           WHO-5 pre- and post. Mean score on
                            well-being).                         intake was 12.5.

PAUSE                       –                                    –                                          –

Green Card Clinic           Centre for Epidemiological           Two most common reasons for ED             Re-attendance rates were 57% at second session and 34% at third session.
(Wilhelm et al., 2007)      Studies Depression Scale             presentations among attendees              21% of attenders were able to be followed up. Of these:
                            (CES-D). (0-60. Higher score         were: overdose (66%); suicidal
                                                                 ideation (17%).
                                                                                                            • 67%                                                 • 16% reported that they had self-harmed again.
                            indicates greater depressive
                            symptoms. Score of 16+                                                                  of these stated they had made positive
                                                                 51% of attenders had a previous              lifestyle changes since attending the clinic;
                            identifies individuals at risk of    reported instance of deliberate
                            clinical depression.                 self-harm.
                                                                                                            There was a statistically significant reduction in symptoms of depression among N=40 participants who attended all three sessions and
                            FANTASTIC lifestyle checklist        •  Mean CES-D on intake (n=282)
                                                                    was 35.7 (s.d.=12.0).
                                                                                                            completed the post-test CES-D (mean 17.9, s.d. = 12.9).
                            (0-50. Higher score indicates
                            greater control over one’s
                            lifestyle)
                                                                 •  95% scored 16 or more, indicating
                                                                    possible depression.
                                                                 •  85% scored 23 or more, indicating
                                                                    significant depression.
                                                                 Mean FANTASTIC scores 25.9 (s.d. = 7.3).

Pieta House (Surgenor       Single item indicator (“I have           Pre-treatment scores were:             Post-treatment scores were:
et al., 2015)               high self-esteem”) rated on
                                                                     •  Mean self-esteem score was 1.76     • Mean self-esteem score was 2.79 (s.d. 1.08);        • Mean negative suicidal ideation was 7.77 (s.d. 4.82);
                            5-point scale (1=low; 5=high)               (s.d. 1.07)
                                                                                                            • Mean PHQ-9 was 10.87 (s.d. 7.47);                   • Mean positive suicidal ideation was 13.76 (s.d. 3.66).
                            Patient Health Questionnaire
                            (PHQ-9). 9-item scale. Lower
                                                                     •  Mean PHQ-9 score was 18.58
                                                                        (s.d. 5.77)                         Changes in scores pre- and post-treatment were statistically significant (p
Co-responder models                                                             Inclusion to the service, if:

Co-responder programs assist first responders by providing
                                                                                •    Ongoing suicide attempt or severe plans;

advice, conducting mobile assessments, and taking                               •    Urgent acute psychiatric condition which requires clinical
                                                                                     assessment for which delay could cause damage to
over the care of a person in suicidal crisis; enabling the
                                                                                     the individual, others, property, or which could cause
first responders to return to duties, avoiding extended                              significant deterioration of the condition;
engagement with the person in crisis, and thus increasing
first responder capacity.                                                       •    Post-partum psychosis1.

                                                                                Exclusion to the service, if:
Psychiatric Emergency Response Team (PAM),
Stockholm, Sweden                                                               •    Panic attacks;
                                                                                •    Reaction to crisis (e.g., death of a family member);
Model description
                                                                                •    The person has already died by suicide;
The Psychiatric Emergency Response Team (Psykiatrisk akut                       •    Isolated substance abuse;
Mobilitet – PAM) operates in Stockholm, Sweden, and attends
emergency calls involving members of the community with
                                                                                •    Medically unstable1.

severe mental illness or acute suicide risk (Bouveng et al.,                    These criteria are checked by the prehospital emergency call
2017). PAM is described as representing a unique approach to                    centre, who act as gatekeepers as to whether PAM
pre-hospital care, that provides the consumer with specialist                   are engaged1.
assessment and intervention, is time efficient (average
waiting time 15-20 minutes, and average assessment time 1                       Over a 12-month period, PAM received 1,580 requests, of
hour 15 minutes), and reduces work load for first responders                    which they attended 80% (n = 1,254). PAM dealt with 1,036
(Bouveng et al., 2017). Suicide prevention is the main objective.               unique individuals, of whom 43% were male, and 56% were
PAM operates from 3pm to 1am daily. PAM is staffed by two                       female. Individuals ranged from 5-100 years of age. The 18-29
specialist psychiatric nurses and a paramedic, who liaise with                  year old age group presented the largest demand, at 27% of
police, paramedics, rescue services and the psychiatrist on                     those in contact with PAM (Bouveng et al., 2017).
call at the psychiatric emergency department, who can provide
                                                                                Of the 1,580 requests for assistance, 1,392 of these were able
advice and assistance, as required (Bouveng et al., 2017). Staff
                                                                                to be classified into the following categories:
are chosen based on their high level of specialisation and
clinical experience in suicide prevention1. PAM staff operate                   •    Severe suicide threat (36%);
a modified vehicle, with space for conducting assessments,                      •    Suspicion of severe psychiatric illness (25%);
delivering psychiatric treatment, and transporting consumers
(Bouveng et al., 2017). The vehicle is equipped with mobile
                                                                                •    Acute crisis (18%);

computer systems to access medical records (prior to or                         •    Severe suicide attempt (6%);
during assessment of the consumer), psychiatric medications,                    •    Suspicion of intoxication/overdose (3%); and
breathalyser, and a defibrillator (Bouveng et al., 2017). Calls
are triaged by the emergency services call centre operator,
                                                                                •    Other (12%; Bouveng et al., 2017).

and the vehicle is dispatched in order of priority, with suicidal               Evaluation
crises a high priority (Bouveng et al., 2017).
                                                                                An evaluation of the PAM service was undertaken for
Consumer characteristics                                                        the year 2015-2016. No clinical outcomes were reported.
                                                                                Outcomes of contact, for the 1,036 individuals that PAM was
In the initial implementation of PAM, dispatch was made                         in contact with, were as follows:
on the basis of clinical judgement; there were no formal
guidelines used to assess which presentations warranted                         •    No action or referral to other services (34%);

attendance by PAM1. Decision-making was based on clinical                       •    Admitted to psychiatric emergency department (25%);
assessment, which included: questioning around presenting                       •    Admitted to substance use emergency department (18%);
problem; consideration of historical factors impacting on the
                                                                                •    Job handed over to paramedics (10%);
suicidal crisis; mental illness history; frequency, duration
and severity of suicidal thoughts, plans, intent; risk versus                   •    Admitted to psychiatric child care (4%);
protective factors and what supports can be utilised in the                     •    Person died by suicide at arrival (0.3%); and
community; and mental status examination1.                                      •    Other or unknown (10%).

More stringent criteria for PAM involvement were implemented
in January 2019, with inclusion and exclusion criteria as
follows:

Olof Bouveng, Lead Author Bouveng et al., 2017. Personal communication via email. 8th November 2018.
1

         12                 PARTNERS IN PREVENTION: UNDERSTANDING AND ENHANCING FIRST RESPONSES TO SUICIDE CRISIS SITUATIONS
OPTIMAL CARE PATHWAYS

The evaluation reported that PAM was well-received by all         Evaluation
stakeholders, and that it may have assisted in reducing
                                                                  There was no consistency across studies in regards to
stigma associated with suicidal crises and mental illness
                                                                  evaluation methods. Numerous studies did not measure
(Bouveng et al., 2017).
                                                                  outcome effectiveness. Of the studies that measured the
Limitations                                                       use of police powers (k = 5), the co-responder model was
                                                                  associated with a reduction in the use of police powers to
No data on clinical outcomes were reported. No pre-data nor       detain an individual, when the co-responder model was ride-
control group data provided.                                      along in person assessment (Puntis et al., 2018). A reduction
                                                                  in psychiatric hospitalisations due to the implementation
Systematic review of co-responder models                          of the co-responder model was found in three studies,
                                                                  however hospitalisations were found to increase in another
Model description
                                                                  three studies (Puntis et al., 2018). Seven studies found that
Puntis et al., (2018) conducted a systematic review of co-        consumers were positive with regards a co-responder model,
responder models. They found differences in design, with          in comparison to previous experiences they had had with
some models involving remote telephone contact only, and          police, however three studies reported that consumers were
others involving mobile teams attending the site in person        dissatisfied with lack of follow up and referral pathways
(Puntis et al., 2018). Of the 26 papers utilised, 19 different    (Puntis et al., 2018). Nine studies reported on perceptions
co-responder models were found:                                   of the co-responder service, finding that service providers
                                                                  viewed the service positively, and that police viewed it
•   Twelve were ride-along, whereby the police officer and
                                                                  neutrally compared to service as usual, with the main
    mental health clinician attended in the vehicle together.
                                                                  limitations being availability of the co-responder and
•   Five encompassed both a ride-along model and                  restricted hours (Puntis et al., 2018). Cost-effectiveness was
    communication support, whereby the clinician can advise
                                                                  investigated in three studies. One study found co-responders
    police via telephone or police radio remotely. Four of
                                                                  to reduce costs by 23%, one study found it reduced policing
    the five predominantly utilised communication support
    remotely, with only serious incidents activating the ride-    costs but increased health provider costs, and one study
    along unit.                                                   found costs increased by less than 1% (Puntis et al., 2018).

•   Two services utilised communication support                   Limitations
    remotely as the only method.
                                                                  The authors identified three major limitations of the studies
Pathway of referral to the co-responder was ascertained for       reviewed:
15 models, and included emergency control rooms (k = 2            1. Service user characteristics were not described
studies), directly from police on location (k = 4), emergency        adequately, if at all;
control rooms plus directly from police (k = 8), and a direct
                                                                  2. Co-responder models were often poorly described and
co-responder phone line (k = 1; Puntis et al., 2018). Operation      there was a wide variation in the operationalisation of
times were variable, ranging from afternoons and evenings            services; and
to 24 hours per day (communication support models only),
                                                                  3. Effectiveness of co-responder models has not been
seven days per week (Puntis et al., 2018).
                                                                     rigorously tested.
Consumer characteristics                                          The authors concluded that despite the increased use and
Males were more likely to be referred to the co-responder         interest in co-responder models recently, overall there is a
teams than females (range 47% – 77% of referrals received)        lack of evidence regarding the effectiveness of such models
(Puntis et al., 2018). Five studies reported mean ages, which     and consumer outcomes.
ranged from 34.7 years of age to 40 years of age. One study
reported that 46% of consumers were between 18-39 years           Australian co-responder models
of age, while two studies reported that most consumers            In Australia, a number of co-responder models have been
were between 35-44 years of age (28%) and 35-54 years of          trialled. This review specifically outlines the evaluations of
age (35%). Three studies reported the most common reason          Australian co-responder units (“the units”):
for referral to the co-responder as: Suicidal behaviour (two
                                                                  1. Police, Ambulance and Clinical Early Response (PACER),
studies); or “Bizarre or disorganised behaviour” (one study)         Melbourne, Victoria (hours of operation not given)
(Puntis et al., 2018).
                                                                  2. Alfred Police Ambulance and Clinical Early Response
                                                                     (A-PACER), Victoria (2pm to 10pm)
                                                                  3. West Moreton Co-Responder Program, Ipswich,
                                                                     Queensland (2pm to 10pm, days of operation not given)

                                                                                                                     13
Model description                                                    •   Section 10 (37%);

The PACER units acted as secondary units engaged by police           •   Family violence (7%);
or paramedic first responders via police communications              •   Assist CATT (2%);
centres, local Crisis Assessment and Treatment Teams (CATT),
                                                                     •   Assist ambulance (2%);
or the police Officer in Charge (OIC) (Lee et al., 2015; The
Allen Consulting Group, 2012). Each unit comprised a police          •   Other (3%; The Allen Consulting Group, 2012).
officer and mental health clinician/s. Some models employed          Most consumers (54%) seen by PACER were a registered
the mental health clinician to be located within the police          mental health client, and most were also known to police.
station, and others involved the police co-responder picking
the clinician up from the local hospital where they would be         A-PACER demographics
located (Lee et al., 2015; The Allen Consulting Group, 2012).
                                                                     During the six-month trial from November 2011 to May 2012,
The units’ aims were:
                                                                     296 contacts were made with A-PACER. Of these, 60% were
•   To provide onsite mental health assessment in a timely           male, and 40% were female (Lee et al., 2015).
    manner. This was facilitated by access to background
    information via a shared police and mental health                Reasons for referral, included:
    database;                                                        •   Threatened suicide (33%);
•   To reduce unnecessary transportation to hospital                 •   Welfare concerns (22%);
    by police or ambulance, through assessing the
    appropriateness of community referral options or not
                                                                     •   Psychotic episode (18%);

    requiring further intervention; and                              •   Assist CATT or police (12%);

•   To assess and facilitate the most appropriate referrals          •   Family violence (7%);
    to those encountered, including to psychologists and             •   Revoked community order (3%); and
    psychiatrists, general practitioners, community based
    organisations, as well as hospital and psychiatric facilities    •   Follow up after prior contact with A-PACER (2%; Lee
                                                                         et al., 2015).
    (The Allen Consulting Group, 2012).
                                                                     West Moreton co-responder program demographics
Consumer characteristics
                                                                     Of 137 people who had direct contact with the unit, 50% were
Inclusion criteria for attendance by the PACER units were:
                                                                     male. Just over one-half (51%) of consumers were between
•   Onsite clinical assessment of the crisis was required (The       20-39 years of age (Meehan et al., 2019).
    Allen Consulting Group, 2012);
•   Onsite or telephone advice was needed regarding referral         The most common reasons for co-responder involvement with
    options (The Allen Consulting Group, 2012);                      the 137 who had direct contact were:

•   Guidance on transport options and de-escalation                  •   Threatening suicide/self-harm (60%);
    techniques was requested (The Allen Consulting Group,            •   Situational crisis (22%);
    2012);
                                                                     •   Threatening harm to others (5%); and
•   Assistance in treatment planning for frequent users of           •   Other not reported (13%).
    emergency services was requested (The Allen Consulting
    Group, 2012);                                                    Personality disorder was the most common diagnosis (22%)
                                                                     with intoxication accounting for 11% of call outs. Previous
•   The clinician had triaged the call and ascertained it was
                                                                     contact with mental health services had occurred in 36% of
    appropriate for attendance (Lee et al., 2015).
                                                                     cases (Meehan et al., 2019).
Demographics of the units are reported below.
                                                                     Evaluations
PACER demographics
                                                                     PACER
During a 16 month period (2009-2011), PACER received 783
assistance requests (The Allen Consulting Group, 2012). No           PACER was evaluated over a 16-month period (1 December,
demographic data were reported on.                                   2009–31 March, 2011; The Allen Consulting Group, 2012). The
                                                                     evaluation design was a pre-post study with control group.
Reasons for referral, included:

•   Welfare concerns (48%, including threatening suicide/            •   Over three-quarters (78%) of assistance requests
                                                                         were responded to on-site. Of this 78%, 82%
    self-harm, threatening harm to others, at risk of harm,
                                                                         received a PACER mental health assessment;
    frightening/delusional behaviour, confused/incoherent);
                                                                     •   In addition, 36% of cases required transportation from
                                                                         the PACER site, compared to 99% in the comparator site;

        14              PARTNERS IN PREVENTION: UNDERSTANDING AND ENHANCING FIRST RESPONSES TO SUICIDE CRISIS SITUATIONS
OPTIMAL CARE PATHWAYS

•      Ambulance transport was used more in PACER (45%) and                           There was a statistically significant reduction in mental
       police transport was used less (40%), compared to the                          health related emergency department presentations for
       comparator site, where ambulance transport was used in                         the six months after the program was introduced (299
       37% of transports and police used in 61% of transports;                        presentations per month pre-program, and 265 per month
•      At the PACER site, 52% of transportations were to hospital                     post-program; Meehan et al., 2019). Surveys of police first
       emergency departments, and 27% were to a psychiatric                           responder intentions as they were leaving the scene indicated
       facility. At the comparator site, 82% of transportations                       that police had intended to transport 82% of consumers to
       were to a hospital emergency department and 12% were                           hospital under an Emergency Examination Authority (EEA).
       to a psychiatric facility (The Allen Consulting Group, 2012).                  However, when co-responders were present, only 23% of
                                                                                      consumers were transported on an EEA (Meehan et al., 2019).
PACER was well accepted by stakeholders, including police,
paramedics, mental health staff, and viewed favourably by                             Limitations
consumers who experienced reduced waiting times, more
flexibility in options for care, less need for transportation                         PACER
to hospital, and better utilisation of resources. The
                                                                                      The evaluation by The Allen Consulting Group (2012) did
authors concluded PACER was more cost effective than the
                                                                                      not report on demographics of consumers. The study
comparator site (The Allen Consulting Group, 2012).
                                                                                      authors noted some limitations due to the fact that police
A-PACER                                                                               and ambulance service staff did not always complete the
                                                                                      Mental Disorder Transfer Forms (L42), the study’s key data
Of the 296 contacts, 32% were transported to emergency                                source. Additionally, the evaluation only reported descriptive
department; 22% were referred to a suitable service; 20%                              statistics, thus limiting the conclusions that can be drawn
were judged as not requiring any further assistance; 11%                              regarding the efficacy of PACER (The Allen Consulting Group,
were directly admitted to a psychiatry ward; and 9% received                          2012).
phone assistance (Lee et al., 2015). Transportation was more
often with police (58% of those needing transportation) than                          A-PACER
ambulance (36%) or other services (6%; Lee et al., 2015).
                                                                                      No clinical outcome data was collected. No pre- and post-
It was noted by the lead author that PACER/A-PACER models                             tests for consumers nor questionnaire for consumers on how
function most efficiently in high density metropolitan areas                          they experienced A-PACER were reported.
where locations are easily reached by car2. Rural areas
                                                                                      West Moreton co-responder program
provide time restraint challenges, as one job may take hours
to respond to2. In these areas, Lee recommended a telephone                           It is unknown whether service users engaged with services
model could be implemented whereby a clinician could                                  to which they were referred, as this information was not
provide advice and assistance via telephone and mental                                gathered or available (Meehan et al., 2019). Additionally,
health trained police officers could respond in person to the                         there has been no follow-up with consumers, nor collection
crisis2. Alternatively, the team could service the town centre                        of clinical outcomes data. No comparator site evaluation was
in larger rural areas, with police being the respondents to out                       conducted.
of town calls with telephone assistance from the clinician2.

West Moreton co-responder program                                                     Brief contact interventions
During the initial 16 weeks of the program, in 2017, the                              Brief Contact Interventions, such as the Distress Brief
co-responder team had direct contact with 137 individuals,                            Intervention (DBI), are time limited, structured, interventions
as well as providing phone advice to other agencies for 44                            that aim to deliver a compassionate and proportionate first
people (Meehan et al., 2019). Information for analyses was                            response to individuals in crisis (The Scottish Government,
available for 122 of the persons who had direct contact with                          2015). Delivery of these interventions should not be reliant
the co-responder team. Of these, 67% remained at the scene;                           on mental health or allied health professionals, but open to
29% were transported to the emergency department; and 4%                              suitably concerned and interested individuals who receive
were taken into police custody (Meehan et al., 2019).                                 appropriate training. These models of contact are time
                                                                                      limited, but involve ongoing contact, employing multiple
Those who remained at the scene were referred to various
                                                                                      forms of communication (e.g., telephone or written contact).
government and non-government agencies for follow up
(Meehan et al., 2019).

2
    Stuart J Lee, Lead Author Lee et al., (2015). Personal communication via email 21st November 2018.

                                                                                                                                        15
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